Prognostic impact of frailty beyond age in cardiogenic shock

Background Chronological age is a major risk factor for adverse outcomes in cardiogenic shock (CS), yet substantial heterogeneity exists within age groups. Frailty has emerged as an important prognostic marker, but its impact across different age strata remains insufficiently defined. Purpose To evaluate the prognostic impact of frailty in patients with CS and to determine whether its association with outcomes differs between younger and older patients. Methods This nationwide retrospective cohort study included adults admitted to intensive care units with CS between 2012 and 2022. Frailty was assessed using the Hospital Frailty Risk Score (HFRS ≥5), and age was stratified as younger (<70 years) and older (≥70 years), yielding four groups. The primary outcome was in-hospital all-cause mortality. Among hospital survivors, long-term outcomes included all-cause mortality, heart failure–related rehospitalization, and post-intensive care syndrome (PICS). Multivariable logistic and Cox regression models were used with adjustment for demographics, comorbidities, and advanced supportive therapies. Results Among 207,419 patients with CS, frailty was present in 40.3% of older and 26.1% of younger patients. In-hospital mortality was highest in older frail patients (39.3%), followed by older non-frail (29.8%), younger frail (24.5%), and younger non-frail patients (16.2%). After adjustment, frailty was independently associated with increased in-hospital mortality in both older (adjusted OR 1.56, 95% CI 1.52–1.61) and younger patients (adjusted OR 1.35, 95% CI 1.29–1.42). Notably, younger frail patients had higher mortality than older non-frail patients. Among 150,433 hospital survivors (median follow-up 3.7 years), frailty remained strongly associated with long-term mortality in both older (adjusted HR 1.31, 95% CI 1.28–1.34) and younger patients (adjusted HR 1.37, 95% CI 1.31–1.42). Younger frail patients also exhibited worse cognitive outcomes. Older patients were less likely to receive advanced therapies, including mechanical circulatory support and heart transplantation, irrespective of frailty status. Conclusion Frailty is independently associated with adverse short- and long-term outcomes in CS across all age groups and may outweigh chronological age in prognostic assessment. Incorporating frailty assessment into treatment decision-making may improve risk stratification and help avoid age-based undertreatment.Main results